Standing Committee D

[Mr. Bill O'Brien in the Chair]

Water Bill [Lords]

Amendment proposed [this day]: No. 213, in 
clause 61, page 76, line 30, at end insert— 
 '(2A) Neither shall a water undertaker be required by subsection (1) above to enter into any such arrangements unless and until it has been ascertained (pursuant to the provisions of section 89 below) that at least 90 per cent. of the population residing within the area proposed to be fluoridated are in favour of the fluoridation of their water supply.'.—[Mr. Wiggin.]
 Question again proposed, That the amendment be made.

Bill O'Brien: I remind the Committee that with this we are discussing the following:
 Amendment No. 351, in 
clause 61, page 76, line 30, at end insert— 
 '(2) With regards to Wales, neither shall a water undertaker be authorised by subsection (1) above to enter into any such arrangements unless and until a referendum on increasing levels of fluoridation has been held in accordance with the Political Parties Elections and Referendums Act 2000 seeking approval of the arrangements from the population residing in the area proposed to be affected.'.
 Amendment No. 156, in 
clause 61, page 79, line 19, after 'below', insert 
 'the Secretary of State must ensure funding is available for the consultation to take place as set out below, and'.
 Amendment No. 110, in 
clause 61, page 79, line 21, after 'consult', insert 'all households'. 
Government amendment No. 338. 
 Amendment No. 158, in 
clause 61, page 79, line 22, at end insert 
 'then if public opinion is clearly in favour of such an addition'.
 Government amendments Nos. 339 to 342.

Robert Key: I was describing how my constituency had been involved in this issue and how both general practitioners and consultants regarded it. As it happens, no fluoride is naturally found in or added to the water. The only place in the Wessex Water area where natural fluoride is found is in the vicinity of Laycock, where the borehole provides naturally fluoridated water to about 14,000 people.
 I want to turn to the national position. We are talking as if we are about to launch a campaign to put fluoride in everyone's water. That would never happen. The British Dental Association points out that of the 659 parliamentary constituencies, only 64 have above-average rates of tooth decay in children up to five years old. We are talking about just under 10 per cent. of constituencies in this country, which means that 90 per cent. of constituencies would probably not see any reason even to hold a ballot, let alone have a local health authority propose that fluoride should be added. 
 An NOP survey found that 67 per cent. of people in Britain think that fluoride should be added to water if it can reduce tooth decay, with 22 per cent. saying no. The same survey found that 42 per cent. of people think that fluoride is added to their drinking water already, when the real figure is that about 10 per cent. have fluoridated water. Most people also do not know that fluoride is present naturally in some water—only 28 per cent. of the population think that it is. The national situation gives us a picture that is less certain than some people would allege. 
 We have debated whether fluoride is a medicine. It has always been my understanding that, as with chlorine or calcium, it is a trace element that is important for human well-being. The process of natural fluoridation or the addition of fluoride could be seen as nanotechnology, and the question is how we get the fluoride to the teeth. That is where the scientific arguments, many of which have been deployed today, can be cited on both sides of the discussion. As the Medical Research Council study reports, it is true that some of the science has not been good or conclusive and that lots more should be done. However, that does not mean that we should stop people from having fluoride in or added to their water. We are in one of those endless scientific debates. 
 My other problem is that, although it would be better in theory if we could leave the issue to the private choice of parents and other adults, preventive medicine has not worked. The evidence for that is in the parliamentary answer from the Minister that I quoted earlier. My constituency has average rates of tooth decay in children, and no fluoride naturally occurs or is added to the water. If I were an MP for an area in which children suffered from poor dental health, if public education had failed for many years, and if fluoride were not already added to public water supplies, I would vote for fluoridation. 
 Some people would say that therefore, by implication, I would be opposed to fluoridation, but that is not the case. There is a compelling argument for walking by on the other side, saying, ''I'm all right, Jack,'' in Salisbury, and ignoring those in areas where there is no naturally occurring fluoride, or where there is particularly bad child dental health. However, I have decided that I am not prepared to pass by on the other side. It is a question of balance and judgment. I have decided that, in this instance, child health must take precedence over my scruples, prejudices and personal views on individual liberty and freedom. 
 The York report concluded that there is no reason to believe that fluoride is harmful to health. I believe that strategic health authorities are better bodies to take decisions than water companies or local authorities. If water is to be fluoridated, water companies must be indemnified. For many years, water companies have been unwilling to move on this issue, for very good reason, and I therefore welcome the indemnity clause that the Government have included. 
 Even if the Government receive sufficient support for clause 61, however, the whole scheme may founder on practical grounds. First, it is unlikely that many health authorities will want to ask for fluoridation 
 and, if they were to do so, the water companies would face practical problems. I have discussed that matter with Wessex Water, the major water company in my constituency. It was pointed out to me that its network of mains distribution crosses strategic health authority boundaries. What would the company do if it found that one health authority said, ''Please fluoridate'' and the other ones said, ''Don't.''? That is one practical reason why the scheme may founder—inside or outside the law courts. 
 I listened carefully to the debate, and I have come to the conclusion that, whatever my reservations and the sincerely held reservations of some of my constituents, the clause to permit fluoridation of the water supplies should be added to the Bill. However, if that happens, there must be the widest possible local consultation. That is what the amendment is about. I suspect that it is a probing amendment—90 per cent. is a jolly good figure to ask for because it sets you thinking. However, I also think that the attempt to improve the health of children's teeth should not be scuppered by a minority of adults who feel passionately that their preference for libertarianism must prevail. 
 I am surprised that the Government have not been able to tell us what arrangements they propose for consultation, and they have simply said that those will follow in regulations. It is a common problem faced in both Houses—part of the parliamentary process—that Governments tend to leave things to statutory instruments that will follow later. No doubt some of the relevant statutory instruments have not even been drafted yet. I scrutinised the Export Control Bill last year, and there were more than 40 regulations that were to follow it, but at least those were available to us in draft form for the debates in Standing Committee. The Government have a duty to prepare those draft regulations as quickly as possible, so that we can see what is proposed for consultation. In my opinion, they should have done so already.

Hugo Swire: I am most grateful to my hon. Friend for giving way and appreciate his concern for children. Is he aware of the report by Mr. Ortiz-Peres and colleagues, which concluded that very low doses of fluoride inhibit the response of follicle-stimulating hormone to inhibin B, and linked that to reduced sperm production? If we were to follow his line of argument, there might be no children in future who need their teeth fixing.

Robert Key: I saw that article, but that argument would not apply to me, since I had a vasectomy many years ago—[Interruption.] Hon. Members may not have wished to know that, but now they do. My hon. Friend's remark illustrates the point that the science is open to discussion. There is no certainty in the science, but the balance is strongly in favour of the fluoridation of water having no general adverse effects. Most of life is about taking a judgment on things, and on balance, in my judgment, the clause should be added to the Bill.

Brian Iddon: I represent a constituency where the dental decay in children is probably some of the worst in the country. The hon.
 Member for Tatton (Mr. Osborne) has already referred to Bolton. I, too, have the table that was circulated to hon. Members showing the number of decayed, missing or filled teeth per five-year-old child. Bury, the neighbouring town to mine, is top of the table. Several of the Manchester constituencies are at the top of the table. The three Bolton constituencies are at Nos. 57, 58 and 59; mine is No. 57. I am ashamed of that, frankly. It is terrible that 70 per cent. of the children in my constituency have serious dental decay at the age of five.
 I must admit that, as the hon. Gentleman said earlier, Bolton has taken a decision about fluoridation, but it did so in 1968, and that was the old Bolton borough, not the present Bolton metropolitan borough council, which is much larger. There was not a referendum such as we have been discussing. Bolton seems to be out of step with Greater Manchester. There are 10 towns or cities in Greater Manchester, and at that time Bolton was the only one that decided against. Seven decided in favour and two, Wigan and Bury councils—we should bear it in mind that Bury is right at the top of the table—had not taken a decision at that stage. 
 In the late 1960s and early 1970s, most of the people in Greater Manchester who had been consulted voted for fluoridation, but that has not happened and children still suffer. By the age of five, the average Bolton child will have experienced quite a lot more than 2.5 decayed teeth, which is much greater than the national average. The situation is far worse in my constituency, which has some of the highest levels of deprivation in the three Bolton constituencies. Some of the wards in my constituency are some of the most deprived in the country. 
 I listened carefully to the hon. Member for Salisbury (Mr. Key). He said that he could take an attitude of ''We're all right, Jack'' in his constituency, but he does not and I am pleased that he considers the people of my constituency and many others where dental decay is at such a high level that all hon. Members should be ashamed. Parliament must try to do something about that. 
 It is all very well people saying, ''Well, you can go out and buy a toothbrush and fluoridated toothpaste.'' The reality is that these parents do not, for whatever reason. Perhaps they are poorly educated. They probably ain't got the brass, and putting food on the table is more important than going out and getting a toothbrush and fluoridated toothpaste. The fact is that many parents do not educate their children about correct dental health procedures, and I do not see why those children in my constituency should suffer because of the neglect—that is what it is, I suppose—of the parents who are meant to be looking after them. 
 In total, 70 per cent. of Bolton's children suffer dental decay at a very early age. I was sitting next to a dentist the other evening, when I addressed the Royal Pharmaceutical Society's annual dinner in Bolton. He was very pro-fluoridation. At his practice in Manchester—I did not ask him which part of Manchester—he sees children with teeth in terrible condition. Two years ago, he could have done 
 something about that—he could have extracted them—but he can no longer do so. Children come into his surgery in intense pain, but there is little that he can do. He certainly cannot extract the teeth, because we have banned general anaesthetic in general practice, and dentists now have to refer people to a clinic. 
 I am told that a few extractions are done at Bolton Royal hospital, but most such children in Bolton go to the Manchester university dental school. Last year, it gave general anaesthetics 1,500 times to extremely young children—I stress the extremely young bit—and on top of that there was a waiting list of 500. Hon. Members who are anti-fluoridation should consider the suffering of those children who cannot have their teeth out immediately in general practice. I accept that they can be given antibiotics or other palliative care, but for curative care they have to wait to be seen at a centre such as the Manchester dental school where the teeth can be extracted. It is shameful that there are so many children in Britain with such poor dental health that some as young as two or three have to have teeth out. 
 I take the point made earlier that things might be better if the dental system was improved. But even if it were, and there were more NHS dentists and people did not have to queue for appointments, it would not be much better than it is at present in the deprived parts of my constituency. 
 I have considered all the arguments, for and against. I appear almost as an Aunt Sally on the National Pure Water Association's website, as people are invited to write to me, which they do. Some of the letters I receive can only be described as fanatical. For example, hexafluorosilicic acid, the main chemical used to fluoridate water, is described as a waste, poisonous product from the phosphate fertiliser industry. One would believe that we were putting children up chimneys to scrape the stuff out. The letters are almost out of this world, and certainly fanatical. I do not say that all members of the NPWA are fanatics, but a minority of people write the most absurd things. If they want to persuade me to their point of view they should not write such letters, but I respond to them all. 
 I make my point to the British Fluoridation Society, too, because those on both sides of the argument have circulated pictures and so on. Both organisations are a bit over the top, but especially the NPWA. 
 Why are hexafluorosilicic acid and its disodium salt being used to fluoridate water? As a chemist, I have given that question careful consideration. The NPWA would say, ''If fluoride is already in water, that is okay; it is natural.'' Belladonna is natural, but I would not dream of taking it. Calcium fluoride comes out of the rocks in the earth but it is insoluble in water. There could not be more than about three, four or five parts per million calcium fluoride in water because of its lack of solubility, so it would be impossible to use calcium fluoride to fluoridate water in a rapidly flowing stream going through the treatment works. 
 The fluoride used in toothpaste is called sodium fluoride. All fluorides when they enter water are ionisable and they end up as fluoride ions; when we talk about, fluoride, that is what we mean. We use hexafluorosilicic acid and its disodium salt because the former is a liquid; it is soluble in water and easy to titrate to one part per million or whatever concentration Parliament decides. It is easy to add to water in that concentration. Of course, I would prefer to use the natural stuff, but it could not be put accurately into the water while it is flowing through a treatment works, and the same applies to sodium fluoride. It is okay in toothpaste, but it could not be added to water. 
 I am concerned about hexafluorosilicic acid, but only a trace—one part per million—is being added. At that level in many areas there are already a fair number of chemicals in water, including fluoride, although I do not want to name them all. In some areas, fluoride occurs at such a high level that the water has to be diluted with unfluoridated water in order to get it down to one part per million. 
 On behalf of my constituents, especially the children, I ask hon. Members to look at the figures and think about the suffering of children, which we can easily prevent. I ask members of the Committee to support fluoridation and not the wrecking amendment.

Sue Doughty: Much of our discussion concerns the heart of the reason for debating the controversial subject of fluoridation. We are talking about the dental health of children and adults. The hon. Member for Bolton, South-East (Dr. Iddon) made a powerful case, with which I am sure the Committee sympathises. One or two of us attended a scientific event today and were paired with scientists, and the insight that it provided on fluoride has been helpful.
 Some questions remain, and I would appreciate help with them. According to the table provided by the British Dental Association, children in Birmingham constituencies are still at risk even with fluoridated water. That problem also exists in Manchester, and I know that the people of Manchester are anxious to put that right. Anomalies still exist over the outcomes in areas where we are putting fluoride in water, and I would like to understand the discrepancy. I do not want to undermine the case for or against fluoride; the question merely comes from my ignorance. 
 Other issues regarding the dental health of children and adults are beginning to give us reason for hope, in particular for the plight of children under the age of five. I agree that some problems arise from deprivation, ignorance, or poor health care during pregnancy, never mind when the child is born. There are also problems with nursing, and ignorance as to whether to give children fizzy drinks or chocolates at an early age. I remember my in-laws being deeply upset when I would not let my children have chocolate before they were five. That was the only time that my children did something I wanted: I could give them a piece of fruit instead and they would be grateful. Those days are long gone, but we had a stay of execution before they were sucked in. 
 There are problems with junk food being advertised to children, particularly the under-fives. Many substances that damage children's teeth are advertised, and I hope that the Government will carefully examine the work being done on the private Member's Bill on TV advertising of food to children. I am sure that that work could have a beneficial effect on children's teeth. 
 Surrey schools, among others, are working towards encouraging children, not to stop drinking fizzy drinks but to drink lots of fresh, tap water through the day as a beneficial health aid that will also help teeth. I understand and agree with the hon. Member for Salisbury that prevention does not always work. I sympathise with that view and support my hon. Friend the Member for Lewes (Norman Baker) in saying that we are not against fluoride, but we question how the decision is made. I am the sort of person who would have taken my children to get their teeth painted—in those days that was available on the national health service and would have sorted the problem for many people. There is a lot of work, and I understand the problems of parenting. 
 Will the Minister further consider what will happen with children's centres? In—

Bill O'Brien: Order. I draw the hon. Lady's attention to the fact that the amendments are about consultation and referendums. Her speech is really for a clause stand part debate rather than relating directly to the amendment. If she will refer to consultation and referendums, that will bring us back to the amendments.

Sue Doughty: I was drawing attention to this subject, because I feel that, as part of the wide-ranging debate, we are left with a problem over health. I will not dwell on that much further, other than to say that I hope that children's centres will provide an opportunity to deal with parentcraft, diet and other problems. We must avoid the scandal of under-fives having problems with extractions, which lead to pain and problems in adult life.
 I support the need for consultation, but any decision must be democratic, or as democratic as we can achieve. I certainly cannot support the idea of 90 per cent., but I appreciate why it was included. We need to consider the means by which we consult local people. We must ensure that where there is an overpowering case—I am sure that there is in Manchester—that decision can be made sensibly. With good health service support, too, we can get the best outcome for children.

George Osborne: I found this one of the most difficult issues to decide on in the short period that I have been in Parliament. It is a classic case of the overwhelming medical and scientific evidence coming up against a quite proper public feeling that reacts against the view that Whitehall knows best about public health and how we should be treated. We encounter that on other issues, such as GM crops, all the time in Parliament. That illustrates one of this country's problems in addressing many
 scientific and medical issues. I did not come into Parliament with a fixed view about fluoridation, and I have made an effort to read all the evidence for and against. To be honest, my mind changes with each new piece of evidence that I read.
 The argument made by the hon. Member for Bolton, South-East is extremely compelling. I represent a constituency on the edge of Manchester, and the state of tooth decay in Manchester is shocking. It is difficult for any person living near Manchester not to be at least forced to think hard about their position when it is pointed out that in Birmingham tooth decay is, on average, much less. On average, children of five do not have tooth decay there, whereas in Manchester the average child has three fillings by that age. When confronted with that evidence, it is difficult to say, ''Well, I'm going to ignore that. People should look after their own dental care, buy toothpaste and brush their teeth.'' In an ideal world, we want people to look after themselves, but we do not live in an ideal world. Tooth decay affects the most deprived communities in the country. That is not just because such communities cannot afford toothpaste and toothbrushes. There is a broader problem of getting people in those communities to take an interest in their health care; that applies to many other things, such as smoking and the kind of foods that they eat. The argument is compelling. 
 Equally compelling is the argument that people should not be medicated—I know that the Minister will dispute my use of that word—or given health treatment without their consent. That is a powerful argument about freedom in our society, and about being forced by Government or Parliament to do things that they do not want to do. 
 I tried to resolve the issue—although, as I shall explain, it did not help—by writing a column. I have a regular column in the Manchester Metro News, which I am sure all members of the Committee have read.

Nick Palmer: Send us a copy.

George Osborne: I shall be happy to read out the whole column. By the way, nobody ever writes to me after I write the columns; I receive no reaction at all—except to this one. I wrote, quite straightforwardly, that an issue was being debated in the House of Commons, I did not know what to think about it and, what was worse, there was to be a free vote on the issue, so the Whips—I am a Whip—would not tell me what to do. I set out as fairly as I could the arguments for and against fluoridation. I had an amazing response. I have here all the letters that I received from people in Manchester and, as I also put the column in papers in my constituency, from people there too. The letters are very compelling. The overwhelming majority were against, and they were not fanatics, as the hon. Member for Bolton, South-East suggested that some people involved in this argument are. They were sensible, well-written letters.
 For example, a Ms Yates said: 
''I buy organic food as much as possible, but would have no choice available to me if the water supply was fluoridated''.
 An e-mail from a Mr. Brumby in Manchester said: 
''Please vote against adding fluoride. I live in a democracy and I believe I have the right to drink water without someone else telling me I have to drink it with fluoride in. Parents should be responsible for their own children''.
 Equally, I received some letters in favour of fluoridation, including from a senior lecturer in primary dental care at Manchester university dental hospital, to which reference has already been made in this debate. It is just the nature of my constituency that I tend to represent all the dentists. They live in Cheshire and commute to their practices in Manchester. 
 I also have almost all the Manchester hospital consultants in my constituency. My constituents are a well-informed bunch. This senior lecturer says that he sees 
''the consequences of the non-fluoridation of the water supply at the sharp end. We hold regular extraction sessions for children under general anaesthetic and I have to listen to the poor kids being escorted out with their families, usually in tears and all in pain.''
 However, he concludes that 
''the benefits of fluoridation outweigh the negative aspects of the mass medication''—
 he uses that word— 
''argument, although I have fierce arguments with my wife on this issue! She is a homoeopath and believes that people should be more responsible for their own health.''
 The matter divides families. The way I have resolved the issue, which is not necessarily to come down on one side of the argument or the other, is to criticise the way that the Government are doing it. Whatever the arguments for and against, it is a decision that should be left to local communities—a phrase that the Minister has used several times today. However, I do not think that the strategic health authority is the right vehicle. 
 My constituency comes under the Cheshire and Merseyside strategic health authority, which covers a vast area that obviously includes millions of people. When my constituents talk about the local community they do not think of themselves as being in the same local community as central Liverpool, Knowsley, St. Helens or even Chester at the other end of the county. One cannot fairly say that the strategic health authority is a representative body of the local community, however good the consultation exercise it carries out. The other problem with giving it to strategic health authorities is that they are seen as having parti pris. They obviously have an overwhelming self-interest in promoting fluoridation. They are not seen as neutral in the argument. 
 Two things would greatly improve this deeply controversial piece of legislation. First, there should be a genuine local referendum. The Government have nothing to fear from such referendums. They have been carried out in the past in this country on this issue. They would be easy to organise. It would be a genuine debate in many cities and regions. In Manchester one could well get a strongly positive vote for fluoridation with the kind of arguments we have heard today. Secondly—this strays slightly into 
 the next group of amendments—this is best dealt with by local authorities. They would be seen as more neutral.

Richard Burden: Birmingham has been referred to so many times that it would be remiss of me if I did not rise to say something. In doing so, I am conscious of how the hon. Member for South Cambridgeshire (Mr. Lansley) referred a couple of sittings ago to putting on his anorak to deal with some amendments. Moreover a commentator who was talking about politics in general and politicians in particular said that one should always be rather suspicious about people who get over-excited about fluoridation. Having received some of the letters and representations that my hon. Friend the Member for Bolton, South-East mentioned, I know what that commentator means.
 We are not immune as politicians. The same commentator said that people should be really worried about politicians who think that the two crucial things to debate are fluoridation and proportional voting systems. I wish to talk about fluoridation, and I chair the all-party group on electoral reform, so I have to take a deep breath in case I get too excited about this. It is important to be clear what the issues are, both in relation to the amendments and the general question. Other Members have said this, but it bears repetition. This is not a discussion about whether fluoride should be added to water supplies. My hon. Friend the Member for Broxtowe (Dr. Palmer) hit the nail on the head when he said that it is a discussion about who decides whether fluoride should be added. 
 If the situation stays the same—and if clause 61 is not passed, it will stay the same—a private water company, and not a health body, will make the decision. The issue is not theoretical, because the Water (Fluoridation) Act 1985 has been on the statute book for a long time and it is not true that local and district health authorities have never made any representations or requests to fluoridate water supplies when it was important for public health. About 50 health authorities submitted such requests, but not one fluoridation scheme has been put into effect. We cannot run away from that fact. 
 The discussion appears to be about who decides and democracy, and I am aware that the people who have campaigned vigorously against fluoridation have taken on board the issue of democracy. However, I did not hear them complaining when the health authorities, which represented local people, sometimes with help from local councillors, were trying to get a debate going and had their efforts thwarted by water companies' decisions. 
 I do not blame the water companies for that. All sorts of pressures pushed them into those decisions, but it is interesting that the campaign for ''democracy'' grows when a decision could be made that leads to the fluoridation of the water supply. We should not ignore the fact that the objective of the people who have been most vociferous is not to secure democracy or freedom of choice but to stop fluoridation schemes. If we lose sight of that, we will miss something important. 
 The question is about who should decide, and in the next group of amendments, we will talk about local authorities. At this stage, I want to say only that although no Member who has spoken has said that it is anything other than a health issue, some people are saying that fluoridation—and fluoridation only—should not be decided through the channels appropriate for all other health issues. Are we saying that because fluoridation is controversial? If so, what do we do about other controversial issues? Public health campaigns about HIV and AIDS are sometimes controversial. Minority campaign groups sometimes do not want primary care trusts or other parts of the health service to take action on such issues, because they are controversial. Should they come out of the health sphere? I do not think so. 
 The accountability of strategic health authorities should be considered. As was mentioned earlier, it would be good if PCTs were fully involved in the consultation undertaken by strategic health authorities. There may also be a case for working out whether the current model of strategic health authority is right. However, that is not an argument for today. The argument for today is whether fluoridation should be tackled as a health issue. If so, the national health service mechanisms should be adopted.

George Osborne: With the greatest respect to the hon. Gentleman, who makes the decision is the issue. We are trying to work out the best vehicle for determining local opinion, and strategic health authorities as presently constituted are not the best vehicle. It may be a health decision, but it could be determined nationally by the Department of Health and Parliament and then implemented through organisations and devices that are better able to gauge local opinion.

Richard Burden: I do not agree. As far as I know, we all agree that circumstances vary from area to area, according to issues such as standards of dental health and the incidence of naturally occurring fluoride. As such, there cannot be a national approach other than an enabling national approach, and this clause is the right kind of enabling clause. If we are to enable anyone on a health issue, we should enable the national health service mechanism. It should be required to consult, involve people, and generate a debate locally, which is why involving the primary care trusts is a sensible idea. However, in terms of the framework, strategic health authorities are the right vehicle.

Ian Liddell-Grainger: I come from Devon—I mean Somerset. I see the hon. Member for South Dorset (Jim Knight) over there, and, although the strategic health authority for Somerset and Dorset is small, it covers a massive area. That is not the right body to do the work. I mentioned Devon because I am from West Somerset, which extends into Devon. The strategic health authority and issues including cross-border piping were brought up earlier, but I do not think that the proposed system would work. It is a
 health matter, but strategic health authorities are too big and unwieldy to deal with it.

Richard Burden: We are being pushed in two directions. We all agree that we must ensure that local people can give their views and be consulted properly. That is important, and it is right to try to achieve that at the level closest to those people. That is why I argue that primary care trusts should be involved. Whether it follows that consultation should be organised at that level is a different question.
 The fact that the supply of water does not necessarily follow administrative boundaries, whether they are local authority or health authority boundaries, might cause us more problems. If we have more local consultations, which are disconnected from each other, there will be greater complexity in the cross-boundary issue. 
 I will wait with interest to see the regulations that will come out, but I believe that we must empower bodies in the national health service, and give them the responsibility for organising consultation at the most appropriate level to reach a decision on fluoridation. We must ensure that, in the context of those responsibilities, the mechanisms for consultation and involvement are as local as possible. There is no contradiction between those two ideas.

David Drew: I am listening carefully to my hon. Friend, and we agree on many things, including electoral reform. However, we do not agree on this. We would all like the NHS to be better at consulting and making decisions after consultation. Can the Minister give me an example of when the NHS has achieved that degree of consultation on such an issue? I do not know of one.

Richard Burden: My hon. Friend is right to be sceptical about the ability of institutions in the national health service to consult properly, and the regulations that emerge will be important to ensure that they do. The requirements to have discussions and involvement on fluoridation may provide a model for greater consultation in the future. If they are going to continue, strategic health authorities will have to tackle that. In the structure of the NHS, primary care trusts at local level may be improving their skills at local consultation and planning of health services—something I want to see. Bringing that together at the strategic, sub-regional level is important whether or not there is fluoridation of water, and whatever happens to the Bill. If the Bill can be used to further that process, I welcome it.

George Osborne: We are not, as the hon. Gentleman is suggesting, debating a method for improving strategic health authorities. I would guess that less than one in a thousand of my constituents knows that they fall under the responsibility of the Cheshire and Merseyside strategic health authority. SHAs are not well known organisations. We have all, as Members of Parliament, seen their efforts at consultation, which seem to involve writing to MPs, primary care trusts and other bodies. They have no experience of carrying out a genuine consultation with members of the public.

Richard Burden: Again, I give the same answer: that is why the regulations are important. In consultation
 with local people, the important factors will be whether they are aware that they are being consulted, the level of information that they have, and the debate that is generated. People will not be bothered about whether the local authority or the strategic health authority conducts the consultation. That is important for us, because we need to work out the mechanisms through which it is done, but the important thing at local level is that the debate takes place.

Bill Wiggin: If I can bring the hon. Gentleman back to the amendment, may I ask him how he envisages that the consultation will be carried out? Will it be a referendum, or will it just be a process of seeking opinion? Will every household be consulted? How does he think that it would take place? It would be interesting to hear his point of view, with his electoral reform hat on.

Richard Burden: I am certainly not suggesting something that is done by single transferable vote. Various mechanisms can be used. In this case, the extent to which we can generate discussion and debate will be as important as the final decision. We could use newspapers and the media, or citizens' juries, which have been pioneered in a range of areas. We need to think imaginatively about how the consultation is carried out, which is why it is best to examine the issue by means of the regulations that will be introduced, rather than trying to determine everything now. If the consultation was reduced to a local referendum, I suspect that that would generate a lot of heat, but not necessarily the discussion that people would like to see.

Hugo Swire: There are all sorts of pitfalls in holding a local referendum and consultation; no doubt some of them will be pointed out later. There are areas such as the constituency of my hon. Friend the Member for Tatton which are largely residential and full of prosperous people who go to another area to work. Would those people be consulted in the area in which they work, because they use the water there during the working day? The area in which they live may not have fluoridated water, because it falls under another strategic health authority. Those aspects must be taken into account.

Richard Burden: The hon. Gentleman is right. That is why it is complicated to work out how the consultation should be done, who should carry it out, and how people can be involved. However, we can all agree that the consultation must happen, and in a way that involves as many people as possible and generates as much knowledge as possible.
 In conclusion, I return to where I started—to Birmingham, which has been the subject of a great deal of discussion in the Committee. My approach to the debate has been determined partly by the experience of Birmingham. The area has been fluoridated since 1964, so I was disconcerted when the hon. Member for Lewes said earlier that the jury was out on that. If that is the case, it is a hell of a long trial—the jury has been out for nearly 40 years. 
 Birmingham still has inequalities in dental health. On average, the dental health of children in lower 
 income groups is worse than that of children in higher income groups. Fluoridation does not get rid of inequalities in dental health; I wish that it did, but it does not. Nevertheless, if one examines the statistics across social groups, one finds that 31 per cent. of children in Birmingham have had tooth decay up to the age of five, whereas in non-fluoridated Manchester, the figure is 62 per cent. Some 13 per cent. of five-year-olds in Manchester have had teeth extracted as opposed to 4 per cent. in Birmingham. When we consider extractions, we should remember the concerns expressed by hon. Members about the impact of general anaesthetics. Those things matter to me, and they cannot be ignored. 
 Perhaps I should take a deep breath before saying what I am about to say, because it may generate more correspondence, but neither the amount of correspondence that I have received from Birmingham people during my time as a Member of Parliament in the city, nor my experience of living there before I became an MP, has led me to believe that there is a huge desire among Birmingham people to get rid of the fluoride in their water supply. 
 I certainly have not detected any of the evidence apparently produced by groups opposed to fluoridation saying that fluoride has been proved to be dangerous to health. It is true that dental fluorosis is at a higher level in fluoridated areas than elsewhere, but evidence for the other things that we have heard about, whether in relation to bones, Down's syndrome or whatever, is simply not there in the Birmingham experience. It is right that those issues are researched, and that the York study drew our attention to the fact that the research so far is not as conclusive or detailed as it should be, but the idea that the report is somehow an argument against fluoridation of the water supply in areas where naturally occurring fluoride is insufficient simply does not stand up to close examination. 
 Talking about the extent to which fluoridation of drinking water supplies reduces dental caries, the executive summary states: 
''The best available evidence suggests that fluoridation of drinking water supplies does reduce caries prevalence, both as measured by the proportion of children who are caries free and by the mean change in dmft/DMFT score.''
 The summary goes on to say that the extent of that is subject to debate, but there is no doubt that it says that the best evidence suggests that there is an impact. It also states: 
''The best available evidence from studies following withdrawal of water fluoridation indicates that caries prevalence increases''.
 Again, the document asks for more research, but it does say that the best evidence indicates that there is a link between fluoridation of water supplies and a reduction in tooth decay. 
 However, talking about allegations that somehow fluoridation causes extra bone fractures and bone development problems, and about cancer studies, the summary states that 
''there is no clear association of hip fracture with water fluoridation.''
 It states that 
''no clear association between water fluoridation and incidence or mortality of bone cancers, thyroid cancer or all cancers was found.''
 The summary is not neutral on those issues. 
 The authors of the York report were right to complain about their findings being over-hyped by those campaigning for fluoridation, but we should not conclude from that that it found no evidence of a link between fluoridation and improved dental health, or that it in any way gave, or said that there was, evidence to suggest that some of the horror stories about the effects of fluoridation were founded on substantial evidence. 
 Yes, this is a controversial issue—it generates heat. Perhaps it is one of those anorak issues, but as lawmakers we need to consider the evidence and make a judgment about what is right in public policy terms. The evidence that I have read, and my experience in Birmingham indicates, that the amendment is wrong and the clause is right.

Melanie Johnson: It is a pleasure to respond to a debate of the quality that we have heard this afternoon and, indeed, this morning. So often we do not do justice to these topics, but on this occasion all members of the Committee, on all sides of the argument, did considerable justice to the issues and spoke with considerable passion. They aired most impressively many of the arguments that needed to be aired on all sides. I shall endeavour to rise to the challenge of responding to the debate in like terms, and to talk about the main issues raised. I shall go through one or two of the amendments, but not in too much detail, because I am conscious that there are other issues still to be discussed in detail.
 I believe that our reason for moving away from the water companies to the strategic health authorities as the vehicle for making decisions about this matter is right. Hon. Members have sketched out the issues involving the difficulties that the water companies had with existing arrangements. That did not result in what many of them had requested concerning the local authority interest in having water companies do things and concerning accountability. 
 We have already teased the hon. Member for Leominster (Mr. Wiggin) about his views on accountability in the private water companies, and I shall tease him no more. It is clear, however, that the strategic health authorities are the right bodies at the right level to make these decision. I shall explain why in more detail. They have a broader oversight of the health and health provision of their area than do the primary care trusts. People have argued that these decisions should be made at PCT level. The PCTs vary in size, and the mechanics of the engagement with water companies—which I shall come on to shortly—indicates that if things were done at PCT level, issues would be magnified many times. The strategic health authorities can, in my experience, rise to the challenge. 
 I shall give an example that has nothing to do with fluoridation—I must be careful what I say, because no 
 decisions have been made and I am a Health Minister. In my constituency area, the strategic health authority has considered, through the PCTs, the future of hospital provision across Bedfordshire, Hertfordshire and north London. That is a big swathe of the area—as big as Somerset and Dorset together, or a number of the other conjunctions that hon. Members have cited as being covered by their strategic health authorities. 
 With the engagement of the PCTs and other councils at a local level, the strategic health authority has communicated with local people in all manner of ways about those proposals. Many views have been received through every avenue that one could hope to have used, including discussion and debate, meetings, the media, questionnaires, petitions, MPs and local authorities. I am not diminishing the importance of this debate by saying that the debate about the future of local hospital provision is probably an even more important question for people than that of whether the water is fluoridated. I am confident that strategic health authorities can rise to the challenge. That, together with the difficulties of the existing arrangements, is why we settled on them as the right vehicle for taking forward the measure. 
 My hon. Friend the Member for Stroud (Mr. Drew) asked about the Government's position on fluoridation. Our position is very clear: we think that there are strong oral health arguments for fluoride which make it a useful answer, if local communities want it. That is why we have taken this route.

George Osborne: The Minister explicitly says, ''if local communities want it''. What advice would she give to a strategic health authority that had decided on medical grounds that it would be good for the area if fluoride was added to water, but which, after public consultation, got an overwhelming negative response? Should it trust its medical instinct or advice, or should it listen to local opinion in that situation? It is a serious point and I think she will find that this happens in many areas.

Melanie Johnson: We are not suggesting a referendum, as hon. Members know. I mentioned the consultation in my constituency. Judgments have to be made in weighing up the thousands of responses generated as a result of widespread consultation over time, as I sketched out.

Hugo Swire: Will the Minister give way?

Melanie Johnson: I shall give way when I have answered the question asked by the hon. Member for Tatton.
 There is a difficulty in weighing up the responses, but whatever the case, local opinion must be in favour of the proposal. It will not proceed if all the indicators are overwhelmingly against it, as the regulation to be introduced will make absolutely clear. Local opinion must support the measure overall.

George Osborne: Will the Minister give way?

Melanie Johnson: I shall give way to the hon. Gentleman and then reply to the hon. Member for East Devon (Mr. Swire).

George Osborne: I am sure that my hon. Friend does not mind. I am reassured by what the Minister said, and by what may be in the regulations. What does she mean by local opinion? Will sheer numbers—the fact that thousands of people write in to say that they are against it—be taken into account, or will more weight be given to the opinion of local doctors and dentists than that of ordinary people, to use that awful phrase?

Melanie Johnson: I hope that the hon. Gentleman is not insulting his many constituents who belong to those two admirable professions. At the end of the day, judgments will have to be made, just as they are in deciding how hospital provisions are to be redeployed in the long term.
 If the hon. Gentleman is asking whether the views of certain professionals will carry more weight, as in a block vote, that should not be the case. We are talking about the opinion of the local community, which means that the views of the ordinary person on the street are taken as seriously as anyone else's.

Andy King: The discussion appears to be about how to introduce fluoridation. Can the Minister clarify what will happen when fluoridation is already in place, and evidence is produced that makes us say, ''Well this is not quite how we thought it would be.''? What mechanisms are in place to deal with such a case? Decisions cannot be once and for ever, because we live in an ever-changing world.

Melanie Johnson: Obviously, we do not expect things to swing backwards and forwards on a pendulum basis. The expectation is that the decision would stand for a considerable time. The water companies would have to make a capital investment in fluoridation so it would cause difficulty if we allowed different views to prevail every couple of years.
 The hon. Member for Leominster and others mentioned the cost of consultation. I do not conceal the fact that there will be such a cost, which will come out of the NHS budgets. However, given the cost of providing dental treatment on a much more significant scale to children and others with decaying teeth on the basis proposed earlier by my hon. Friend the Member for Bolton, South-East, there would probably not be a net cost—there may even be even be a saving—but that would not be the reason for doing it.

Hugo Swire: I am grateful to the Minister for giving way, and for the delay in doing so, because it has prompted another thought. Can she confirm what she has just said, that the costs of consultation will be absorbed by her Department, and not passed on to the taxpayer? Does that also apply to fluoridation? Will the water companies bear the cost, or will it be passed on to the hard-pressed taxpayer?

Melanie Johnson: No, in both cases the costs will be borne through NHS funding. That is the proposal.

Hugo Swire: I will now ask my original question, if I may. Given our discussions about how the consultation would work in practice, has the Minister had a chance to consider the problem that would arise if one area was keen to have fluoridation and another area, which was under the same or a
 neighbouring health authority and shared certain pipes, was vehemently against it? How would that problem be resolved?

Melanie Johnson: That situation is almost bound to crop up. I certainly foresaw that it would be an issue early on. The water distribution systems do not cover exactly the same areas. Nothing overlaps exactly in anything here. There is obviously no overlap with any other mechanism for making these decisions either. Boundaries are not coterminous. There would need to be discussion if the water company was going to cover an area wider than the strategic health authority by fluoridating its water at a single source, for example.
 When I talked to someone in the water industry about this matter informally, I was told that it was possible to fluoridate at different points in the water distribution systems, depending on the company and the way that the distribution takes place. Therefore it can be done nearer or further away from the customer and with more or less fine-tuning. That obviously will not overcome all the difficulties that hon. Members have described, but it would overcome many of them. 
 There will be occasions when two strategic health authorities may need to have discussions with a part of a population that might be affected by a decision in a neighbouring area. There could be a marginal additional cost for example to remove that area from the water distribution system and put in the supplies nearer to the sources so ensuring that it covered a more limited area that was more naturally coterminous with the strategic health authority boundaries.

Norman Baker: Two points flow from that. First, if we are to take local opinion seriously, decisions need to be taken—whether or not they are organised by the health authority—about local communities within the health authority area. Brighton and Hove, for example, might be in favour and the rest of east Sussex might be against. The water company should be required to respond to sophisticated public opinion, even if that is more expensive, rather than try to make the case that it is more convenient for it to put the necessary works further up the chain, which would mean that others would get fluoride whether they wanted it or not.
 Secondly, I should like to make a point in response to the intervention by the hon. Member for Tatton about the tests that will be applied by the consultation process. Under clause 61, the proposed new section 89(1)(a) to the Water Industry Act 1991 states that 
''a relevant authority shall . . . consult and ascertain opinion in accordance with regulations''.
 I am not sure whether that is qualitative or quantitative. Are there any circumstances in which public opinion may be either divided equally or be marginally against fluoridation but the health authority would nevertheless still wish to pursue that course of action for other reasons? Is public opinion the only test? If so, may I draw the Minister's attention to amendment No. 158, which, if I understand her correctly, is what she is trying to achieve? It says that this should be progressed only 
''if public opinion is clearly in favour of such an addition''.
 Is she attracted to that amendment?

Melanie Johnson: I have already said that we think that it should be done only when public opinion is in favour, and the question is how to sum up public opinion. As well as the careful judgments and difficult balances, which Members have sketched out well in their contributions, that is another judgment that may have to be taken by some strategic health authorities if there is a carefully balanced view. Whatever mechanism is used, a clear majority of people should be in favour of fluoridation.

Bill Wiggin: One of the questions I posed at the beginning of the debate—the 90 per cent. quoted in the amendment is tempting the Minister to discuss this—was about the meaning of a clear majority. The hon. Member for Birmingham, Northfield (Richard Burden) outlined many types of consultation, for which I was grateful. The point that we are coming to, which will reappear in the next amendment, is what she means by a clear majority.

Melanie Johnson: I am grateful to the hon. Gentleman for picking up on my exact words, because they were probably misleading. One reason why we have sympathy with the intention of amendment No. 158 is that we agree that the strategic health authority should not be permitted to fluoridate unless the local community is in favour. I have already sketched out the mechanisms and issues involved in reaching that conclusion.
 Fluoridating water makes a difference, as many Members have already said. However, the 70 per cent. of my hon. Friend's constituents who are five years old or under and have experienced tooth decay is in stark contrast with the number in other areas of the west midlands and Crewe. The figure in the west midlands is one third of that, and in Crewe the figure is 23 per cent. 
 The hon. Member for Guildford (Sue Doughty) asked about some areas in Birmingham and the midlands that experience considerable problems with tooth decay, gum disease and dental health. In deprived areas, even if the water is fluoridated, tooth decay levels may be at or above the national average. That is not to say that improvement has not taken place; indeed, the situation would have been worse without it. Everybody will not be at the same level because other factors are involved. 
 The hon. Lady also mentioned children's centres and the role that we can play in encouraging other contributions to dental health. Those points were well made and have been taken on board. We are attempting to give young people and their families the best possible start, with a number of programmes designed to help and advance that. 
 I turn to the question raised by my hon. Friend the Member for Stroud on amendment No. 338. The reason for introducing the differential in that amendment is to distinguish between the Secretary of State, who is the ultimate reference point for the English health service, and the National Assembly for Wales, which is relevant for the Welsh health service. 
 The Secretary of State will set the regulations for England, which is why we have introduced amendments that deal with the different position of the English and Welsh health systems.

David Drew: I accept what the Minister says, but I think that that wording should be in the Bill, and I hope that it will be redrafted on Report. To me, the term ''appropriate authority'' could mean any body. The drafting should be tidied up.

Melanie Johnson: I take that point on board and will discuss it further with officials. I imagine that parliamentary counsel will tell us that the drafting is right and means that the legislation can be clearly understood, but I understand my hon. Friend's difficulty.
 I take issue with my hon. Friend's dismissal of the cards from dentists. One interesting point is that, if we look at the debate from a purely financial point of view, dentists benefit most from dental decay. It is admirable that so many of the dental profession are arguing the case for fluoridating water, because their pockets will be most at risk if people's dental health improves substantially. I have been fortunate throughout my life in having good dental health, so my dentist has not often profited from me. 
 In response to the hon. Member for Lewes, gum disease and dental health problems are relevant and both need to be addressed. Fluoridation will considerably reduce tooth decay, while gum disease is reduced by many other oral hygiene measures. It is not either/or, it is both.

Norman Baker: I agree that it is not either/or, but hon. Members were concerned that if people knew that fluoride was being added to water as a health benefit, they might conclude that it was less necessary to visit the dentist, and other dental problems not related to tooth decay could increase.

Melanie Johnson: I suppose that we could not rule that out in a limited number of cases, but I am not aware of any evidence from fluoridated water areas to substantiate that claim.
 I have already sketched out the mechanisms that are relevant for a strategic health authority in considering public opinion and making a decision, and they will be subject to regulations debated under the affirmative resolution procedure. The hon. Member for Leominster was gracious in admitting that the amendment was a wrecking or exploratory one—

Bill Wiggin: A probing amendment.

Melanie Johnson: I see. I trust that the hon. Gentleman will not advocate the 90 per cent. level too strongly outside this Room, because otherwise I imagine that the right hon. Member for Chingford and Woodford Green (Mr. Duncan Smith) might become nervous about both him and his continuing in his present role.
 I will run through a couple of the other amendments, which hon. Members have not addressed but which are probably important to mention. Amendment No. 351 is designed to amend and clarify the respective responsibilities of the 
 Secretary of Sate and the National Assembly for Wales. As I said, the Secretary of State will make regulations for England and the National Assembly will make them for Wales. The hon. Member for Ceredigion (Mr. Thomas) passed me a note this morning to say that he has another appointment this afternoon and cannot be here, but I am sure he would be interested to learn that.

Kevin Brennan: Just to remind my hon. Friend that the hon. Gentleman is not the only Committee member from Wales. I am listening carefully to what she has to say about provisions affecting Wales.

Melanie Johnson: I am well aware of my hon. Friend's interest.
 On amendment No. 156, I appreciate that hon. Members are concerned that consultations are adequately funded. We will set out in regulations the procedures that the strategic health authority must follow in undertaking a consultation, and it will be advised not to embark on one if it has not identified the funds for so doing. 
 I am in sympathy with the spirit of amendment No. 110. We want to ensure that as many of the people as possible that would be affected by a proposed fluoridation scheme participate in the consultations. We would hope to consult more widely than just with residents; we would want to include people who work in the area, and who perhaps spend most of their day there.

George Osborne: Amendment No. 110 would add a requirement to consult all households. In the regulations that will be introduced, will the presumption be that the strategic health authority will send consultation literature to every household in the area affected?

Melanie Johnson: That is the sort of thing that we have in mind. The regulations will be subject to the affirmative procedure, so I do not have a draft with me and cannot confirm specific details. However, we believe that some sort of door-to-door consultation must be part of the overall consultation.

David Drew: Can the Minister assure me that both sides of the argument will be included in the consultation? Otherwise, it will not be true consultation.

Melanie Johnson: I certainly think that we would want to include material setting out both sides of the argument, with input from different places. However, that regulation would again be subject to the affirmative procedure.
 Amendments Nos. 338 to 342—I shall not discuss them in detail—all relate to the Secretary of State and the National Assembly for Wales, and the way in which the regulations should reflect the different position in Wales. Amendment No. 341 provides for the Secretary of State and the National Assembly to make a written direction for the termination of all, or one or more specific fluoridation schemes. 
 The reason for going through all those amendments in relation to Wales and England is to clarify the respective responsibilities. That is essential for the 
 implementation of our policy, which is to give local populations a choice over whether they want their water fluoridated. 
 I commend amendments Nos. 338 to 342 to the Committee. I also thank hon. Members for their contributions to the debate. Many of us feel that the matter under discussion is important, but I hope that Opposition Members will not press their amendments.

Bill Wiggin: I have also enjoyed the debate, which has been informative. We have had some useful expert opinions, and much of what I have heard has been reassuring. I am grateful to the Minister for her support for amendment No. 110, which would ensure that every household is consulted. I thought, and she confirmed, that if a majority were in favour of fluoridation, that would provide a much more compelling argument for it to proceed. My hon. Friend the Member for Tatton neatly explained how individual Members may find the decision-making process difficult on a subject in which the science is debated.
 I should like to put the Minister on notice, so to speak, because the next amendment deals with local authorities and strategic health authorities, and I was not comforted by the comments that she made about the strategic health authorities in her opening remarks. However, in the light of the fact that they would be forced to accept a proper majority—

Melanie Johnson: Perhaps I can be clear with the hon. Gentleman, because he picked me up on this issue and I said that we were saying that no strategic health authority should fluoridate unless local opinion was in favour. As long as he is interpreting my remarks in that context, I am happy with his paraphrase of them.

Bill Wiggin: The next amendment will give us an opportunity to debate what a local population is, but surely the phrase ''in favour'' is the key. If 49 per cent. are in favour and 51 per cent. are against, surely the Minister will accept that that is not acceptable for what we are discussing. Does she agree that there will be a numerical way of defining who is in favour and who is against?

Melanie Johnson: The issue is not as clear-cut as the hon. Gentleman makes out, for the reasons that I sketched out when I referred to the Bedfordshire, Hertfordshire and north London consultation discussion about the future of hospital and other services. How does one weigh up a signature on a petition against someone attending a meeting or writing a letter? One cannot simply do a straightforward crude summary and say that there was a majority one way or the other. We have to consider these things in balance.

Bill Wiggin: I agree, but that is why consulting all households would include everyone in a satisfactory way. I accept the criticisms of consultation. Personally, I would prefer a referendum. I was asked earlier whether I would prefer a referendum and I want to say categorically at this stage that I would. I am sorry that I did not say that more strongly at the time, because it is becoming increasingly clear that, when dealing with a subject as emotional as this—no one could fail to be moved by the case of the children in Bolton—we must
 ensure that it is pinned down in a proper and clear way.
 I remind the Committee that the consultation will be 
''in accordance with regulations made by the Secretary of State''.
 That is why we have to keep returning to the Minister to clarify exactly what she means about the consultation and how it is interpreted. That is why I personally prefer a referendum. It is less difficult to understand how the consultation has been weighed up when there is simply a straight numerical vote. That said, I recognise that the amendment, with its 90 per cent. numerical weighting, would be impractical. 
 There are good arguments in favour of fluoridation. Equally, there are good arguments against. The only way in which we can ever get a satisfactory response is to ensure that everyone has their say and, more importantly, that there is a fully informed debate. Therefore, when dealing with all households or whatever form the consultation takes, it is very important that whoever is in charge is clearly seen to be neutral. I am glad that the Bill says 
''made by the Secretary of State'',
 because obviously one person will declare an interest if they are not neutral. We can trust the Secretary of State to take a neutral stance—well, I hope we can. I find that much more comforting than allowing what we are discussing to be done by the strategic health authorities. 
 There is another side to the issue, which local communities will have to deal with. We have touched on the leakage problem that water authorities and water companies have, and there is an element of accumulation with fluoride. It goes into someone when they drink it and it is absorbed through the skin when they are in the bath. Some of it is excreted and some remains in the teeth. However, if there are large amounts of leakage, we will be putting a toxin into the ground or wherever the leakage takes place, which is a serious issue. In addition, I hope that when water is taken out of and put back into rivers, the fluoride will be taken out, because it can constitute hazardous waste in a more concentrated form. 
 The Minister referred to who would take precedence if two authorities overlapped and one local community clearly wanted fluoride and one did not. She led us to believe—I am sure that she will intervene if I am wrong—that efforts would be made to provide fluoride to the areas that wanted it and not to those that did not. The situation in my area is particularly difficult. The strategic health authority is in Coventry, and it takes me nearly as long to get to Coventry as it does to get here. It is a huge area across the west midlands with a vast number of people. Much of the water in my constituency comes from Wales, and would come under a different strategic health authority. There are difficult problems with that, and I am not sure that the Minister's guidance has been sufficiently clear.

Melanie Johnson: I shall give what I think is an accurate reflection of the hon. Gentleman's comments. Much of the water in Birmingham comes from large dams in Wales, and some small areas in Wales receive fluoridated water as a result of being linked to that system. That is nothing new, nor is the question of fluoride being left in water and going into the waste systems. The only difference is that it is not an issue for the 6 million who already have fluoridated water.

Bill Wiggin: It would be easy to leave it at that, but we are talking about a small amount—one part per million is a very small amount—going into the environment. That is not something that the Government, or any hon. Member present, would normally encourage. Having made the point, I am prepared to leave it at that. There were a couple of points that I thought it important to pick up.

Brian Iddon: In the water cycle, if fluoride gets into the ground, it will be washed out eventually; it is soluble in water. I ask the hon. Gentleman to remember that there is rainfall all the time, which will wash the fluoride away. I do not understand his point about contamination of the ground. In any case, at one part per million, we are talking about one person in a town four times the size of Bolton, which has 261,000 people. We must get things in proportion. The amount of fluoride going into the ground, even over decades, would be trivial.

Bill Wiggin: I am grateful for the hon. Gentleman's intervention; of all hon. Members who have been most informative he has probably been the best. I was talking about fluoride going into rivers, not the sea, but as I said earlier, it is a very small amount. The issue is not so much the quantity as the principle that we are putting a toxin back into the environment when normally people in our position are trying to do the opposite.
 Finally, I should like to chide the Minister, if I may, for something that she said. I am sure that she regrets it, too, because after hearing speeches such as that of the hon. Member for Bolton, South-East, about children, surely nobody would want people to stop using their toothbrush. Unfortunately, that seems to be what she said. 
Miss Johnson indicated dissent.

Bill Wiggin: A headline in The Independent was ''Dump your toothbrush, says health minister''. Words from the Minister's letter are quoted. I shall give her the article. I am grateful to her for denying that people should dump their toothbrush, because I am sure that she—

Melanie Johnson: May I put the record straight? I believe very strongly in the use of toothbrushes, and encourage my children to use them from the earliest possible age. In response to a question from the hon. Member for Guildford, I endorsed her enthusiasm and the importance of continuing to brush teeth. I have no idea where that report came from.

Bill Wiggin: I can help the Minister. The report says:
''Melanie Johnson wrote to MPs last week informing them that brushing requires 'ongoing positive personal action by the individual'. But people who drink fluoridated water can protect their teeth 'without needing to take any personal action'.''
 I accept that that is wrong.

Melanie Johnson: This refers to a letter that all hon. Members have received.

Bill Wiggin: Indeed. The Minister is right, and I am glad that she has taken the opportunity to set the record straight. It is most unfortunate that she should be quoted in such a way, and I am sure that all members of this Committee agree with her that toothbrushing must continue. I thought that she would be aware that she must be careful, because obviously she would not want to send the wrong message.

Norman Baker: May I request a vote on amendment No. 158? I will say something if the Committee wants me to, but in the interests of speed, I am also happy not to. The amendment would simply require public opinion to be
''clearly in favour of such an addition''
 before fluoride could be added, following a consultation process. The Minister said that she wants that to happen, and as it is a very important point of principle, it should be in the Bill, notwithstanding the fact that it may be in regulations.

Melanie Johnson: We will not support the amendment in a Division, but I repeat my assurance: the phrase will be included in the regulations when they are introduced, but it should not be in the Bill.

Bill Wiggin: Will the Minister ensure that the regulations provide for every household to be consulted?

Bill O'Brien: What does the hon. Gentleman want to do with the amendment?

Bill Wiggin: As the Minister has nodded to indicate that all households will be consulted, I beg to ask leave to withdraw the amendment.
 Amendment, by leave, withdrawn.

Bill O'Brien: Amendment No. 158 will be dealt with towards the end of the sitting.

Bill Wiggin: I beg to move amendment No. 301, in
clause 61, page 76, line 33, leave out from 'a' to end of line 35 and insert 'local authority'.

Bill O'Brien: With this it will be convenient to discuss amendment No. 157, in
clause 61, page 79, line 20, at end insert 
 'request the elected local authorities within its area to'.

Bill Wiggin: We now come to thorny issue that the Minister mentioned earlier: the fitness of a strategic health authority to carry out the full consultation that we want, including every household.
 Will the Minister tell the Committee how a strategic health authority is appointed? My understanding is that worthy people are nominated and appointed to it, essentially by the Government. I am happy to stand corrected if I am wrong about that.

Melanie Johnson: I do not have the details, but historically, certainly before the Labour Government
 took office, there was a great deal of potential, and perhaps actual, political involvement. To reassure the hon. Gentleman, my understanding is that the process is now entirely separate from the political process, and appointments are made through the public appointments mechanisms, which are independent.

Bill Wiggin: I am reassured in one respect, but not that the quality of consultation will be as local as it might be. That is the reason for the amendment. I touched on my sense of distance from the strategic health authority when I said that it was in Coventry, which is a considerable distance from Herefordshire. Despite the qualities of the public appointments mechanisms that the Minister valiantly described, they are not accountable in the democratic sense as a method of selection.
 Strategic health authorities do the best they can. They have a clear mandate, and they get on with what they do, but if they did not it would be difficult to discover where they went wrong and what they had not done. To a great extent, that is because the primary care trusts are at the sharp end of local health delivery, and that is why the proposal needs to be localised. 
 There is another reason, which arose in earlier debates. The perception is that dentists, doctors and scientists—people in white coats—are all in favour of fluoridation. One might think that that is also a strong argument in favour of fluoridation, and I would accept that, with due respect to those professions, but when we are dealing with such an emotive issue, we should start from scratch. The consultation process should not be run by people with an agenda. 
 It is well known that returning officers do not vote, and if they appear to have any political allegiance they are ruled out. We need a fair consultation process. We need it to be seen to be fair, transparent, open and straightforward, as I know the Minister would like it to be. That is why local authorities are the right people to run the consultation process and the strategic health authorities wrong. 
 There is another fundamental problem. Strategic health authorities do not coincide with the water authorities. The reason for choosing strategic health authorities is perhaps that the Government could not think of anything else for them to do or any other body they could have started with.

Melanie Johnson: May I be bold on behalf of the strategic health authority and suggest that it would welcome a visit from the hon. Gentleman?

Bill Wiggin: It takes me less time to get from here to Hereford than it does to visit my strategic health authority. One day I shall make that trek to visit them.

Melanie Johnson: Bold man.

Bill Wiggin: Well, I have to say that I have never been invited to visit my strategic health authority. This matter does not give me sleepless nights.

Robert Key: I visited my strategic health authority only last month and I found it a rewarding experience, which I recommend to my hon. Friend.

Bill Wiggin: I am delighted to hear that. For that reason alone, I will make every endeavour to visit my strategic health authority. No doubt it will wish to consult me on fluoridation when the time comes. The important point is that such authorities are not local in any sense of the word. The strategic health authority in the west midlands is more than 100 miles from many places in its remit.

Nick Palmer: The hon. Gentleman suggested that the local authority should conduct the consultation. Does he suggest that local authorities should take the final decision, and how many local councillors does he know who know more than even we do about medicine?

Bill Wiggin: The hon. Gentleman makes an important point about who makes the final decision. That is why I pressed earlier for a clearer consultation process so that the people making the decision were the people who would drink the water, not a panel of experts. That is the same reply that I gave when he asked me about referendums. That is the next part to the argument. Should we appoint a strategic health authority to make a health decision in what is essentially supposed to be a democratic process? That cannot possibly be the right way of handling it.
 I can understand why the Government want to handle it in that way, but I do not think that that gives the individuals who consume the water the freedom of expression that they should have. That is why I will press the amendment. It is an extremely important debating point for the Committee. We must get this part right. We have had to concede that the consultation process will not be a referendum. It will be more arbitrary. Therefore I should like to see a neutral platform conducting—

Bill O'Brien: Order. I draw hon. Members' attention to the fact that this is a narrow amendment. I appeal for co-operation in keeping to it.

Norman Baker: You will certainly have that from me, Mr. O'Brien. This is exactly the issue that I want to address. A strategic health authority is not the appropriate body to be solely involved in this. First, it is unelected. Secondly, it is unaccountable to the local community. It is accountable only through the Secretary of State, which is not a direct mechanism for the local community. The word ''local'' has been emphasised by all sides.
 Thirdly, fairly or otherwise, a strategic health authority will be perceived to be biased. Health bodies have largely made up their minds that fluoridation of water is a good thing. When they are responsible for the consultation and perhaps for co-ordinating the material that is sent out, they will be open to accusations that the material is loaded because it quotes this but does not quote that. The material may be entirely balanced but those accusations will still be made against them. That is why it is important, if we are not to be derailed on this, that the body that carries out the consultation is seen to be neutral. That is why many of us prefer local authorities here. Amendment No. 157 differs slightly from the Conservative amendment. The Conservatives want to 
 use local authorities throughout. We suggest that the health authority should 
''request the local authorities within its area''.
 That is a subtle difference. We recognise that there is a strategic view—and we are trying to go along as far as we can with the Government on that—to find some common ground. However, we are saying that the process itself should be carried out by local authorities, even if a health authority initiated it, so that the accusations—which will be made—of bias and distance, and of unelected bodies being involved, can be dealt with in a sensible way. That would mean that we could get on to discussing in the communities whether fluoride should be added to water, rather than whether the body carrying out the work is biased. That suggestion is intended to help the Minister. 
 Local authorities and people on the ground have independence, and they have taken on board local opinion. They may not be skilled or have the necessary qualifications, but they are in touch with local people and they will listen carefully to them. The value of that must not be undermined. The strategic health authorities may wish to be the co-ordinating bodies, but they must involve local communities in a democratic way, and there is no evidence at the moment that they will do that. 
 I say to the hon. Member for Leominster that I do not know where my strategic health authority is—I will discuss that with my hon. Friend the Member for Guildford. It could be said that I should know and that it is remiss of me not to. [Interruption.] Apparently, my hon. Friend does not know either. We represent constituencies in Sussex and Surrey, and neither of us knows where our health authority is. I am occasionally in touch with the authority, but I do not know where it is based, although I know that it is somewhere near me.

Sue Doughty: To clarify that point, it is not that my hon. Friend and I do not talk to our strategic health authorities but, because of the geographical situation, their officials tend to come to London to talk to us. We converse with them, and e-mail and phone them, but we do not know where they are based.

Norman Baker: That is exactly the case. [Hon. Members: ''They will know where the base is tomorrow.''] Yes, my hon. Friend and I will know that tomorrow: I shall go and check it tonight. I think that it is nearer my hon. Friend's constituency than it is to mine, but she might prove me wrong.
 We converse with and write to the authority's officials. If we do not know where they are, that does not suggest that they are very local; and if they do not impinge on our consciousness in that way, it is likely that, with the best will in the world—and regardless of whatever snide remarks people might want to make about Liberals—they will not have impinged on the consciousness of most people in the area, for whom they purport to speak on this important issue. 
 I ask the Minister to recognise that if the issues that I am raising are taken on board, that will aid the process rather than hinder it.

David Drew: I shall take note of your advice, Mr. O'Brien, and speak entirely on why we need to re-localise this process and re-link with local government. Before anyone asks, I know exactly where my area health authority is. It is in a huge black hole: that is how things have ended up because Bristol, Bath and Swindon are involved. I will add nothing more on that sore point, except to say that I am in regular contact with that authority.
 This is an important matter. I hope that the hon. Member for Leominster will press this amendment to a Division. Where we come from in relation to this debate is important. Some of us genuinely believe that one of the problems with our health service is that it is not accountable enough. The mechanisms are not in place whereby it can easily find out what its population wants in terms of health. 
 This is one of the issues about which I think that there would be a great deal of public interest. It might not be on the same scale as the interest in genetically modified organisms, but some people might be surprised to find that many members of the public, when they listen to the arguments, will be very interested in the debate. It is a gut-reaction issue that will take off. It might not have taken off in other Members' areas yet, but it has certainly taken off in mine. 
 I passionately believe that if we look at the Berlin wall—to borrow the words of a previous Secretary of State—between social care and the NHS on a day-to-day basis, it is clear that in recent times we have never arrived at an acceptable relationship between them. I am talking about local government and the NHS. Because of that wall, we will have real problems when we need to try to find out what people think about this issue. 
 The Conservative amendment is right. I accept that parliamentary draftsmen might have to try to make more sense of it, but it is at least a stab at trying to reconnect with what should be happening. There should be a mechanism whereby we can genuinely convince people that fluoridation is right. 
 I listened carefully to the scientific advice that my hon. Friend the Member for Bolton, South-East spoke about, and I shall not demur from that powerful case. However, that case must be made to the general public before we fluoridate their water, rather than afterwards in the hope that they go along with it. That is where local government has more expertise, although it often feels excluded from health matters. We have given local government responsibility for the economic and social well-being of its community, and there is nothing more connected with such matters than what we are discussing. It connects with what the Government are trying to do. 
 I passionately support the foundation hospitals debate. Apart from being about mutualism, which I, as a co-operator, believe is a different way to run services, it is also about trying to connect with the population by making them members and giving them a stake in how a public service is run. There are different arguments about that in different parts of the health service. The foundation hospitals debate connects 
 directly with the current debate. If things are put in place through local government, people will feel much more empowered and will be more likely to vote. There is no better way to proceed. That is better than having a false consultation process. With the best will in the world towards my hon. Friend the Minister, I have to point out that she may not be there to make a decision on different areas in which there may be confusing results. 
 The alternative way would be much more straightforward; it would take note of what people say. If we are serious about having such debates—and are doing more than pretending to listen to people's views—let us proceed according to some form of democratic accountability. Otherwise, people will feel that they have not been listened to, and that consultation had been taken just to reinforce the decision.

Melanie Johnson: I want to make it clear that appointments to strategic health authorities are made by the NHS Appointments Commission. That is done independently through the usual proper Cabinet Office procedures and those appointments are externally advertised.
 On amendments Nos. 301 and 157, I should like to reassure hon. Members who have contributed to the debate that we have resolved that local authorities should play a major part in reaching decisions on whether an area should fluoridate. I do not agree with what hon. Members said about the strategic health authorities. I shall not rehearse the argument about their connection with their area and the role that they can play. There have been some pertinent developments in the organisation of the health service and the relationship between it and the local authorities in recent times. 
 One such development took place under the Health and Social Care Act 2001. All the county councils, London boroughs and unitary authorities have established local authority overview and scrutiny committees. The strategic health authorities and primary care trusts are required to consult those committees where there are to be significant changes to health services. We need to put a ring-holder in the Bill and name a ring-holding organisation. I am convinced that the strategic health authorities are the right ring-holding organisations; none the less, they must engage with the wider community in a meaningful way, including engaging with the local authorities and playing a major part in the decision and consultation-making processes for such matters. The strategic health authorities are, in any case, required to consult the local authority scrutiny committees. 
 My experience of talking with people in local authorities about health and public health matters is that already much stronger links are being made in many areas between local authorities and health authorities, including strategic health authorities and primary care trusts. Those committees represent a forum for the SHAs to sound out local authorities on the proposal to fluoridate, and to enlist their co-operation in organising the wider public consultation; they represent a very important avenue. I was a local authority member for some 16 years, and 
 I would not want to downplay the importance of local authorities. 
 In terms of the democratic processes involved, it is important to stress that neither the views of SHA members nor those of local authority members should determine whether an area is fluoridated. As we have all been saying, it should be determined by the views of the local population.

Norman Baker: Will the Minister confirm, if she can at this stage, who will be responsible for producing the literature that will doubtless be part of any informative campaign to help people choose? Will it be the strategic health authority?

Melanie Johnson: The hon. Gentleman is pressing me a little too hard on the detail. That is the sort of thing that could be part of the regulations that will be introduced subject to the affirmative procedure.
 Partnerships, which are already represented through the scrutiny committee arrangements, and using the organisations that are part of those same partnerships throughout local authorities and the health service more widely are useful ways for a body, such as a strategic health authority, to move forward consultation and engagement of the kind that we are discussing in relation to the proposal to fluoridate water in a given area. The role of local authorities, strategic authorities and other health organisations will be to hold the ring to ensure that comprehensive consultations take place and that there is an objective assessment of people's views. 
 I reassure the hon. Members who tabled the amendments that we are not very far apart in where we want to be on these matters. However, I believe that they are best addressed not in the Bill but through the detail of regulation. In light of my assurances, I hope that the hon. Member for Leominster will withdraw his amendment.

Bill Wiggin: The Minister was kind to be so sympathetic towards the amendments. Unfortunately, these amendments need to be added to the Bill. It is as simple as that.
 Question put, That the amendment be made:—
The Committee divided: Ayes 8, Noes 12.

Question accordingly negatived.

Melanie Johnson: I beg to move amendment No. 320, in
clause 61, page 77, leave out lines 3 to 6.

Bill O'Brien: With this it will be convenient to discuss the following:
 Amendment No. 214, in 
clause 61, page 77, line 6, after 'of', insert 'up to'. 
Government amendments Nos. 325, 326 and 334. 
 + Amendment No. 352, in 
clause 61, page 79, line 8, after 'State', insert 
 'as regards England and the National Assembly for Wales as regards Wales'.
 Government amendments Nos. 335 to 337.

Melanie Johnson: I have a detailed speaking note, but I might not inflict all of it on the Committee, depending on their interest in the detail of the amendments.

Elliot Morley: There may not be any.

Melanie Johnson: Well, that is another way of putting it.
 Government amendments Nos. 320, 325, 326 and 334 to 337 consolidate and refine the provisions implementing target concentrations of fluoride. Amendment No. 320 deletes the reference to targets that is now provided in amendment No. 326, and amendment No. 325 omits section 87(9) of the Water Industry Act 1991, which provided for third parties to add fluoride to a water supply and for operational blending. We originally thought that we would need a reference to third parties to provide for licensed water suppliers supplying fluoridated water, but we now realise that that can be covered by the access agreement between the undertaker and the licensee. 
 I am happy to hear what interest members of the Committee have in the detail of the amendments, and I will then be able to respond to their remarks.

Bill Wiggin: The amendment in my name seeks little from the Bill other than to limit the amount of fluoride to a concentration of 1 mg per litre. The amendment would insert ''up to'' after ''of'' in line 6 on page 77.

Melanie Johnson: One milligram per litre? Or 1 part in a million?

Bill Wiggin: The Minister should read what it says on page 77, line 6: ''milligram per litre''. However, I think that we know what we are on about. [Interruption.]

Melanie Johnson: Yes, I think that we do know what we are on about, but my hon. Friend the Member for Bolton, South-East knows better than anyone else.

Bill Wiggin: What an extraordinary statement! I hope that the Minister is right. I was reading from the Bill.
 When we have studied evidence—and hon. Members have referred to the pictures of teeth that they have been sent—we have compared areas of Britain where the water is fluoridated with those where it is not, but we have not looked at the same thing in the United States. Some of the evidence from the US shows that as the concentration of fluoride rises, the number of fluorosis cases rises. At levels of about 
 3 parts per million, the number of cases is extremely high. 
 The amendment would not prevent fluoride from being put in water, but it would make sure that the chemical concentration was limited to 1 mg per litre or 1 part per million. I think that it is a worthy amendment. In high concentrations, fluoride is a poison. It is concentration that determines toxicity, and so it is right that such a chemical be regulated properly. That is what the amendment would do.

Andrew Lansley: I have one question, and I hope that the Minister can respond to it. The issue with target concentrations is that everything, including Government amendment No. 326, seems to be based on there being no difference between naturally occurring fluoride and fluoride that is artificially introduced into the water supply, and no variation in the impact of such concentrations on water hardness, for example.
 The Medical Research Council's first recommendation for research—which, I understand, is ongoing and has not yet been published—is about what is termed the bio-availability of fluoride. I understand that to mean the take-up into the body tissues of fluoride that occurs naturally rather than artificially. The assumption underlying further research is that the bio-availability of artificial fluoride may be higher than that of natural fluoride. I do not understand why that would chemically be so, but I will not linger on it. Assuming that they are not the same—research may show that to be right or wrong—it would be reasonable for target concentrations to vary according to the level of naturally occurring fluoride in areas in which it was intended to supplement it with artificially added fluoride.

Melanie Johnson: We do not yet have the detail of bio-availability, but topping up naturally occurring fluoride in water to a certain level, or watering it down because the water is naturally fluoridated at a much higher level than desirable, can both take place. The Government do not want to see the level rise above 1 part per million. I am not sure about the basis of this debate, because the points being made on the amendments all suggest that we might allow the level to exceed that, but we are clearly saying that we will not.

Andrew Lansley: My argument was not that there should be a different level, but that if the bio-availability of forms of fluoride differs, we should work to a range rather than a specific target. We should vary the extent to which we top up the levels with artificially occurring fluoride according to the bio-availability of those different forms.
 Amendment No. 326 covers what is reasonably practicable, but that does not relate to what is desirable for achieving the optimum level of fluoride, taking into account its different properties. The legislation ought to follow the research rather than the research following the legislation. The drafting should include a range, perhaps 0.8 to 1.2, or 0.6 to 1 part per million, as a better mechanism for allowing for the results of future research.

Melanie Johnson: I understand the drift of the hon. Gentleman's remarks, but 6 million people receive fluoridated water, some of which is titrated down to 1 part per million, some topped up to that level—I am not sure how much is topped up—and some artificially added to. On that basis, we have not felt obliged by any evidence to reduce the level not to be exceeded from 1 part per million.
 The phrase, 
''so far as reasonably practicable''
 is designed to allow for the fact that, when fluoride is added to water, it may be slightly watered down. If we were to demand exactly 1 part per million, it would be difficult and expensive for water companies. The passage of fluoride through the water supply and the position at which the supply is fluoridated will mean that the figure may drop below 1 part per million. As the Minister for the Environment has reminded me, we do not want the level to exceed 1 part per million, and that is what the arrangement is designed for.

Bill Wiggin: I suggest to the Minister that the statement in amendment No. 326 that fluoride concentration in the specified area should be
''maintained at the general target concentration''
 is worrying Opposition Members. If she could provide tighter wording, as my hon. Friend the Member for South Cambridgeshire suggested, we would be content with a phrase such as ''a range'' or ''not greater than''. When we are dealing with a chemical as contagious as fluoride, it is only fair to have tight wording about its concentration. That is good government, and I hope that the Minister takes the point seriously.

Melanie Johnson: I understand the hon. Gentleman's point, which is probably about the word ''target''. The target level is a form of words used to encapsulate the difficulty of keeping the rate at precisely 1 part per million.

Bill Wiggin: It does not have to be exactly that.

Melanie Johnson: No, it could be slightly different. I take the hon. Gentleman's point, and we will examine whether the wording could be better devised. I should point out that a power to change the level of fluoride by order is given under new section 88A. I can tell the hon. Member for South Cambridgeshire that if new research, such as the bio-availability work, showed that we should adjust the level, it would be possible to use new section 88A to do that.
 I take the point made by the hon. Member for Leominster; I think that I understand it now, and I undertake to consider further the wording that we are using. 
 Amendment agreed to.

Melanie Johnson: I beg to move amendment No. 321, in
clause 61, page 77, line 10, leave out 
 'The terms may, for example,' 
 and insert 'Those terms shall'.

Bill O'Brien: With this it will be convenient to discuss the following:
 Amendment No. 215, in 
clause 61, page 77, line 10, leave out 'may, for example' and insert 'shall'.
 Amendment No. 216, in 
clause 61, page 77, leave out lines 11 and 12 and insert— 
 '(a) requiring reimbursement by the relevant authority to the water undertaker of all the undertaker's capital and operational costs of or in any way related to the fluoridation of the water supply;'. 
Government amendment No. 322. 
 Amendment No. 217, in 
clause 61, page 77, line 17, at beginning insert 
 'Before making a request under subsection (1) above,'.
 Government amendment No. 324. 
 Amendment No. 218, in 
clause 61, page 77, line 27, at end insert— 
 '87AA Fluoridation arrangements: technical guidance 
 (1) Without prejudice to Chapter III of this Part and the Health and Safety at Work etc. Act 1974, the Secretary of State and the Assembly shall jointly prepare and issue a code of practice containing guidance on the technical standards that must be met by water undertakers in relation to the fluoridation of water supplies. 
 (2) Such code of practice shall— 
 (a) include such provisions, and 
 (b) be prepared and made in such manner, 
 as shall be prescribed by regulations made by the Secretary of State.'.
 Government amendment No. 327. 
 Amendment No. 219, in 
clause 61, page 78, leave out lines 20 to 34 and insert— 
 '(3) Subject to such safeguards as may be prescribed by regulations made by the Secretary of State, where a water undertaker is required by any such arrangements to add fluoride to water which it supplies to any area, the undertaker may, to such extent and for such time as may be reasonably necessary to accommodate any operational exigency— 
 (a) not supply such fluoridated water to the area required to be fluoridated; or 
 (b) reduce the concentration of fluoride in the water required to be fluoridated to below the required concentration. 
 (4) In this section, ''operational exigency'' means— 
 (a) any serious deficiency in supply; 
 (b) any accident or unforeseen circumstance; 
 (c) the carrying out of any works (including cleaning and maintenance) by the undertaker concerned or, as the case may be, by the undertakers concerned, or by a licensed water supplier supplying water using its or their supply system; 
 (d) any contractual obligation on the undertaker concerned or, as the case may be, on any of the undertakers concerned, or on a licensed water supplier supplying water using its or their supply system, to supply water of a particular quality; or 
 (e) any other operational circumstance which involves the undertaker concerned or, as the case may, any of the undertakers concerned, or a licensed water supplier supplying water using its or their supply system, varying the source or sources of the supply of water to the area in question.'. 
Amendment No. 223, in 
clause 61, page 80, line 15, at end insert— 
 '90A Fluoridation arrangements: precondition 
 A water undertaker shall not be obliged to enter into any arrangements under section 87 above until the Secretary of State has made regulations under sections 87AA and 89 above.'.

Melanie Johnson: Amendments Nos. 321 and 322 respond to requests from the water industry, which asked us to clarify the arrangements that strategic health authorities may make with water undertakers to fluoridate their water. Amendment No. 321 ensures that all arrangements provide for payments to the undertaker for adding fluoride, the circumstances in which the fluoridation can be temporarily suspended and for variations to be made in the arrangement.
 Amendment No. 322 enlarges on the costs that the water undertaker will be able to recover from a strategic health authority under arrangements to fluoridate. It also specifies that both the capital cost of setting up the scheme and the recurring running costs would be recoverable. The Government amendments also cover the intentions behind amendments Nos. 215 and 216. 
 In light of Government amendment No. 324, amendment No. 217 seems excessive. Strategic health authorities will discuss proposals with the water undertaker in advance of any public consultation, so it will be alerted to any issues that need to be raised with the Water Services Regulation Authority in advance of consultation. Otherwise, the regulation authority can be brought in at the time of the public consultation. 
 Amendment No. 324 was also suggested by the water industry. It requires strategic health authorities to consult water undertakers about the boundaries of the distribution system and technical constraints before commencing public consultations on a proposal to fluoridate. They will also need to undertake prior consultation if they propose to terminate a scheme. The intention is to ensure that strategic health authorities appreciate at an early stage whether the water distribution system serves the area of more than one strategic health authority and whether they need to collaborate on public consultations. It will also avoid raising public expectations about proposals that are not technically feasible. Water undertakers have a key role at every stage of the development of a fluoridation scheme, and I am grateful to the water industry for its sensible suggestions. 
 On amendment No. 218, we recognise the importance that the water industry attaches to observance of a technical code of practice. We are already working on a new, updated version of the code, which contains guidance that may need to be updated in light of technical developments. Prescribing guidance in regulations could cause delays in updating the code. 
 I hope that I have reassured hon. Members that we are already updating the code and intend that it will inform all arrangements. I therefore trust that they will not press their amendments to a Division. 
 Amendment No. 327 amends new section 87A, which provides for the determination of any disputes between strategic health authorities and water 
 undertakers on making arrangements to fluoridate. As drafted, the section provides for the determination of disputes that arise over the making of new arrangements, and the amendment includes any disputes that might occur when a strategic health authority wants to vary the arrangements that are already in place. 
 For example, a strategic health authority might decide that it wanted a variation if the oral health of the population had improved so much in one part of its area that it no longer needed to be fluoridated. The strategic health authority would ask the water undertaker for a variation to switch off part of the area fluoridated. We are not expecting many discussions or disputes between the strategic health authorities and the water undertakers, but we have provided for arbitration to avoid the possibility of legal actions. 
 On amendment No. 219, we accept the need to give water undertakers the discretion to cope with unforeseen circumstances such as droughts, floods and plant breakdowns, which have been provided for in new section 87B. We have also extended the provisions in section 87(7)(a), (b) and (c) in the existing Act, which, in the circumstances in which the requirement for fluoridation may be temporarily suspended, allows them to be specified within the terms of the arrangements. Section 87(6) provides for a local agreement of those arrangements. I would need more persuading to go further than that and, given the above assurance, I hope that hon. Members will not press amendment No. 219 to a Division. 
 With regard to amendment No. 233, there is no question of our expecting water companies to fluoridate without indemnities or before regulations on consultation, and I hope that hon. Members will not therefore divide the Committee on that.

Bill Wiggin: It would be extremely churlish of me to challenge the Government on the amendment, as it is almost identical to mine. The Minister is right to concede that, and to have heaped praise on Water UK, which should be congratulated on having worked so hard to get the best possible legislation for water companies. The parallels happily continue until amendment No. 219, on which the Minister said that she would need further persuasion, and we will seek to do that.
 I am grateful for the progress that we have made. It is nice to have a wry smile, rather than the Minister pulling my leg. 
 Amendment agreed to. 
 Amendment made: No. 322, in 
clause 61, page 77, line 11, leave out from 'requiring' to end of line 12 and insert 
 'the relevant authority to meet the reasonable capital and operating costs incurred by the water undertaker in giving effect to the arrangements;'.—[Miss Melanie Johnson.]

Melanie Johnson: I beg to move amendment No. 323, in
clause 61, page 77, line 20, at end insert— 
 '(8A) If two or more relevant authorities request a particular water undertaker to enter into arrangements in respect of adjoining areas— 
 (a) the authorities shall cooperate with each other so as to secure that the arrangements (taken together) are operable and efficient; and 
 (b) if suitable terms are not agreed for all the arrangements, a combined reference may be made by the relevant authorities under section 87A below to enable the terms of each set of arrangements to be determined so that they are consistent. 
 (8B) If a relevant authority requests a water undertaker to vary arrangements, the authority shall cooperate with any relevant authority for an adjoining area which has entered into arrangements with the same water undertaker so as to secure that following the variation the arrangements (taken together) will be operable and efficient. 
 (8C) If suitable terms are not agreed for a variation mentioned in subsection (8B), a combined reference may be made by the relevant authorities under section 87A below to enable the terms of the variation to be determined so that (following the variation) both sets of arrangements are consistent.'.

Bill O'Brien: With this it will be convenient to discuss Government amendments Nos. 328 to 333.

Melanie Johnson: The amendment arises from our better appreciation of the relationship between the boundaries of the water distribution systems and the strategic health authorities. There are 24 water companies in England and 28 strategic health authorities and inevitably there are instances in which a water distribution system overlaps, as we have discussed before. There are also overlaps in Wales. There could be a case in which two strategic health authorities, or a strategic health authority and the National Assembly for Wales, would have to co-operate to undertake joint consultations of the population served by the water distribution system. If the populations were supportive, those bodies would have to co-operate in negotiating agreements. We discussed some of those matters earlier, in passing, and I am happy to discuss them in further detail, if hon. Members wish to do so.
 Amendments Nos. 328 to 333 provide for the situation in which a water distribution system spans the border between England and Wales. In that situation, it would be necessary for an English strategic health authority and the National Assembly for Wales to collaborate, where possible, on the making of arrangements. Amendments Nos. 328 to 331 are consequential on amendment No. 332.

Bill Wiggin: The Minister is talking about consultation and making arrangements. Could she tell us more about the arrangements, and how she envisages that co-operation taking place?

Melanie Johnson: Given that, in some circumstances, two strategic health authorities will need to co-operate—the same would be the case if the National Assembly for Wales were involved, although obviously it is a different sort of body—provision is made for establishing arrangements for collaboration.
 We want to avoid conflicting determinations holding up the implementation of a scheme that populations support on both sides of a border. Amendment No. 329 gives the Secretary of State and the Assembly the powers to appoint a third party to determine the fluoridation arrangements. We have in mind, for example, someone such as a retired engineer or a lawyer from a water company without any 
 connection with the undertaker involved in any dispute, so that such matters can be dealt with as expeditiously and efficiently as possible. 
 At present, we are not aware of any proposals for cross-border fluoridation schemes, but as I mentioned earlier, the west midlands relies on Wales for much of its drinking water, so it makes sense to provide for such an eventuality, even though we are not anticipating the issue coming to the fore. I commend the amendments to the Committee. 
 Amendment agreed to. 
 Amendments made: No. 324, in 
clause 61, page 77, line 20, at end insert— 
 '(8D) Before carrying out the consultation required by subsection (1) of section 89 below in relation to a step mentioned in paragraph (a), (b) or (c) of subsection (2) of that section, a relevant authority shall consult the water undertaker in question as to whether the arrangements which would result from taking that step would be operable and efficient (or, where it is proposed to terminate the arrangements, as to whether it would be reasonably practicable to do so).'. 
No. 325, in 
clause 61, page 77, leave out lines 21 to 27. 
No. 326, in 
clause 61, page 77, line 27, at end insert— 
 '87ZA Target concentration of fluoride 
 (1) Arrangements under section 87(1) above shall include provision for securing that, so far as reasonably practicable, the concentration of fluoride in the water supplied to premises in the specified area is maintained at the general target concentration of one milligram per litre. 
 (2) But the arrangements may provide for the concentration in the specified area (or any part of it) to be lower than that if the relevant authority considers that it is not reasonably practicable to achieve the general target concentration in the specified area (or that part of it). 
 (3) Any such lower concentration must still be as high as is reasonably practicable in the circumstances. 
 (4) If, in relation to any area (''area A''), an order under section 88A(1) below specifies a general target concentration lower than that for which any arrangements effective there provide (or, by the previous operation of this subsection, are taken to provide), the arrangements shall have effect from the coming into force of the order as if they provided for the general target concentration specified in the order (subject to the operation again of subsections (2) and (3) above). 
 (5) If the result of the operation of subsection (4) above in relation to arrangements in area A is that in an area adjoining area A (''area B'') it is not reasonably practicable to maintain the concentration of fluoride in the water supplied by virtue of arrangements made in area B with the same water undertaker, the order shall be taken to extend also to area B so far as those arrangements are concerned, and subsection (4) above shall apply accordingly. 
 (6) An order under section 88A(1) below which in relation to any area specifies a general target concentration higher than that for which any arrangements effective there provide (or are taken to provide by virtue of subsection (4) or (5) above) does not have effect to increase the concentration for which the arrangements provide (or are taken to provide). 
 (7) In this section, ''specified area'' means the area specified in arrangements under section 87(1) above.'. 
No. 327, in 
clause 61, page 77, line 30, leave out from 'agree' to end of line 31 and insert '— 
 (a) the terms of arrangements requested by the relevant authority pursuant to subsection (1) of section 87 above; or 
 (b) a variation in the terms of those arrangements following a request by the relevant authority pursuant to subsection (7)(c) of that section.'. 
No. 328, in 
clause 61, page 77, line 32, after 'England', insert 
 '(except where subsection (3A) below applies)'.
 No. 329, in 
clause 61, page 77, line 35, leave out from 'State' to end of line 36 and insert 'may— 
 (i) determine the terms of the arrangements as he sees fit; or 
 (ii) refer the matter for determination by such other person as he considers appropriate; and'.
 No. 330, in 
clause 61, page 77, line 37, after 'State', insert 
 'or, as the case may be, the other person'.
 No. 331, in 
clause 61, page 77, line 38, after 'Wales', insert 
 '(except where subsection (3A) below applies)'.
 No. 332, in 
clause 61, page 77, line 45, at end insert— 
 '(3A) Where the Assembly is one of the relevant authorities which has made a combined reference under section 87(8A)(b) or (8C) above— 
 (a) the terms of the arrangements shall be determined by a person appointed by the Secretary of State and the Assembly acting jointly; and 
 (b) the determination of that person shall be final.'.
 No. 333, in 
clause 61, page 79, line 3, at end insert— 
 '( ) But (except where it is reasonably practicable to terminate the arrangements separately), arrangements to which section 87(8A)(a) or (b) applied may only be terminated by the relevant authorities acting jointly.'''.
 No. 334, in 
clause 61, page 79, line 8, leave out 'Secretary of State' and insert 'appropriate authority'. 
No. 335, in 
clause 61, page 79, line 9, leave out '87(5)' and insert '87ZA(1)'.
 No. 336, in 
clause 61, page 79, line 15, after 'made', insert 
 'by the Secretary of State (or by the Secretary of State and the Assembly acting jointly)'. 
No. 337, in 
clause 61, page 79, line 16, at end insert— 
 '(4) In subsection (1) above ''appropriate authority''— 
 (a) in relation to an area which is partly in England and partly in Wales, means the Secretary of State and the Assembly acting jointly; 
 (b) in relation to an area which is wholly in England, means the Secretary of State; and 
 (c) in relation to an area which is wholly in Wales, means the Assembly. 
 (5) An order amending or revoking an order under subsection (1) above made by virtue of subsection (4)(a) above must also be made by the Secretary of State and the Assembly acting jointly.''.'. 
No. 338, in 
clause 61, page 79, line 22, leave out 'Secretary of State' and insert 'appropriate authority'.—[Miss Melanie Johnson.]
 Amendment proposed: No. 158, in 
clause 61, page 79, line 22, at end insert 
 'then if public opinion is clearly in favour of such an addition'.—[Norman Baker.]
 Question put, That the amendment be made:—
The Committee divided: Ayes 9, Noes 11.

Question accordingly negatived. 
 Amendments made: No. 339, in 
clause 61, page 79, line 23, leave out 'any prescribed requirements' and insert 
 'the requirements set out in regulations made by the appropriate authority'.
 No. 340, in 
clause 61, page 79, line 33, leave out from beginning to 'requirements' in line 36 and insert— 
 '( ) Regulations— 
 (a) under paragraph (a) of subsection (1) above shall include provision about the process which relevant authorities are to follow for the purposes of that paragraph; 
 (b) under paragraph (b) of that subsection shall include provision about the'.
 No. 341, in 
clause 61, page 79, line 41, leave out from beginning to end of line 2 on page 80 and insert 
 'if the appropriate authority so directs by an instrument in writing (and such a direction may apply either generally or in relation to a particular proposal).'.
 No. 342, in 
clause 61, page 80, line 2, at end insert— 
 '( ) In this section ''appropriate authority''— 
 (a) in a case where two or more relevant authorities (one of which is the Assembly) propose to request a particular water undertaker to take a step mentioned in subsection (2)(a), (b) or (c) in respect of arrangements in adjoining areas, means the Secretary of State and the Assembly acting jointly; 
 (b) in relation to England (except in a case to which paragraph (a) applies), means the Secretary of State; and 
 (c) in relation to Wales (except in a case to which paragraph (a) applies), means the Assembly.'''.
 No. 343, in 
clause 61, page 80, line 9, at end insert— 
 '(1A) The Secretary of State may also, with the consent of the Treasury, agree to indemnify any licensed water supplier in respect of liabilities which it may incur— 
 (a) in supplying water to which fluoride has been added by a water undertaker by virtue of any such arrangements; 
 (b) (if the licensee is introducing water into the water undertaker's supply system) in complying with any obligation imposed on it by the undertaker in consequence of the arrangements.'.
 No. 344, in 
clause 61, page 80, line 13, after '(1)', insert 'or (1A)'.—[Miss Melanie Johnson.]

Melanie Johnson: I beg to move amendment No. 345, in
clause 61, page 80, line 16, leave out subsection (7) and insert— 
 '(7) For section 91 (pre1985 fluoridation schemes) there is substituted— 
 ''91 Pre1985 fluoridation schemes 
 (1) With effect from the appointed day, relevant pre1985 arrangements shall be treated for the purposes of this Chapter as if they were arrangements entered into by the water undertaker in question with the relevant authority under section 87(1) above. 
 (2) The relevant authority may request such modifications to the arrangements as it considers necessary in order to give effect to subsection (1) above, for example to insert the terms mentioned in section 87(7) above. 
 (3) If the relevant authority and the water undertaker fail to agree the modifications requested by the authority— 
 (a) subsection (2), (3) or, as the case may be, (3A) of section 87A above shall apply as if the parties had failed to agree the terms of arrangements requested under section 87(1) above; and 
 (b) following determination of the modifications— 
 (i) the relevant authority shall give notice of the determination to the water undertaker; and 
 (ii) the arrangements shall be deemed to have been modified as so determined with effect from the day after the date of the notice. 
 (4) Sections 87(8D) and 89(1) above (which relate to consultation) shall not apply to the deemed entry into, and modification of, arrangements by virtue of this section. 
 (5) References in this Chapter to arrangements entered into under section 87(1) above shall include arrangements treated as entered into by a water undertaker by virtue of subsection (1) above. 
 (6) In this section— 
 ''the appointed day'' means the day on which section 61 of the Water Act 2003 comes into force; and 
 ''relevant pre1985 arrangements'' means arrangements in pursuance of which a scheme for increasing the fluoride content of water was being operated by a water undertaker by virtue of paragraph 1 of Schedule 7 to this Act immediately before the appointed day.''.'.

Bill O'Brien: With this it will be convenient to discuss Government amendment No. 347.

Melanie Johnson: I will endeavour to be quick in the hope that we will reach the last group.
 Amendment No. 345 deals with existing fluoridation schemes. We have included provisions on fluoridation in the Water Bill because of the flaws in existing legislation that originated in the Water (Fluoridation) Act 1985. The flaws have prevented the introduction of any new schemes since 1985, so all current schemes are pre–1985. The amendment will provide for schemes to be treated as if they have been established under the Water Industry Act 1991 as amended by the clause. There is a lot more detail that I can go through, if hon. Members want me to do so.

Bill Wiggin: The whole Bill is a series of amendments, so I am curious about why amendment No. 345 was not included initially.

Melanie Johnson: I am not sure that I can answer that.
 New subsection (1) provides schemes to be treated as if they have been established under the 1991 Act as amended by the clause. New subsection (2) provides 
 for the strategic health authority to request the water undertaker to modify the arrangements under which the existing schemes operate. New subsection (3) gives strategic health authorities access to the arbitration arrangements that we have introduced in new section 87A if they are in dispute with a water undertaker about terms of modification. New subsection (4) disapplies the requirements for consultations that apply to proposals for new schemes. This is because the existing schemes were the subject of consultations prior to inception and their commencement cannot be contingent on consultation.

Bill Wiggin: I want the Minister clarify one point. Does the new version of the consultation, which we have debated today, supersede that provision, or was it prescriptive on this initially?

Melanie Johnson: I am not clear about the hon. Gentleman's question.

Bill Wiggin: Was the consultation process already in legislative form? Was it provided for in a previous Bill, which means that it has not been superseded? Or was it up to the Secretary of State, as we are now legislating?

Melanie Johnson: I may have to write to the hon. Gentleman. The lawyers are looking in their books, but I am afraid that I do not have the answer.

Bill Wiggin: They are not looking very hard.

Melanie Johnson: They are, but they are not looking at the right ones.
 New subsection (5) provides for all references in the relevant chapter of the Water Industry Act 1991 to apply to the existing schemes as if they had been introduced under new section 87(1). New subsection (6) explains the new status of the existing schemes that will come into force. Amendment No. 347 provides for certain outstanding applications, and new subsection (11) gives the criteria for selection. 
 The provisions are needed because the health authorities consulted on several proposals to fluoridate their water in the 1990s that were supported by the local population, and in several instances, the water undertakers were sympathetic but could not accept the application for technical reasons. For example, they were uncertain about the indemnities available to them. 
 To answer the earlier question, the Water Industry Act 1991 contains consultation provisions, which are presumably being superseded by these provisions.

Bill Wiggin: That does not answer the question, and I would be grateful if the Minister wrote to me.

Melanie Johnson: I will be delighted to write to the hon. Gentleman.
 It being Five o'clock, The Chairman proceeded, pursuant to Sessional Order C [29 October 2002] and 
 the Orders of the Committee [16 September and 21 October 2003], to put forthwith the Question already proposed from the Chair. 
 Amendment agreed to. 
 The Chairman then proceeded to put forthwith the Questions necessary to dispose of the business to be concluded at that time. 
 Amendments made: No. 346, in 
clause 61, page 80, line 16, at end insert— 
 '( ) In section 213 (powers to make regulations), after subsection (1) there is inserted— 
 ''(1A) But on the occasion of the first exercise by the Secretary of State of the power to make regulations under each of sections 89 and 90 above, the instrument containing the regulations shall not be made unless a draft of the instrument has been laid before, and approved by a resolution of, each House of Parliament.''.'. 
No. 347, in 
clause 61, page 80, line 18, at end add— 
 '(9) With effect from the commencement day, any relevant application shall have effect for the purposes of subsection (1) of section 87 of the WIA as a request made by a relevant authority under that subsection. 
 (10) Any other application made before the commencement day ceases to have effect on that day. 
 (11) In subsections (9) and (10)— 
 ''commencement day'' means the day when this section comes into force; and 
 ''relevant application'' means an application which— 
 (a) was made before the passing of this Act; 
 (b) has not been withdrawn; and 
 (c) has not been rejected in writing by the water undertaker to which it was made. 
 (12) In subsections (10) and (11) ''application'' means an application made under section 87 of the WIA as it was in force at the time when the application was made (and includes an application made under section 1 of the Water (Fluoridation) Act 1985 (c.63) and having effect as if made under section 87 of the WIA).'.—[Miss Melanie Johnson.]
 Motion made, and Question put, That the clause, as amended, stand part of the Bill:—
The Committee divided: Ayes 14, Noes 6.

Question accordingly agreed to. 
 Clause 61, as amended, ordered to stand part of the Bill. 
 Bill, as amended, to be reported.